Provider Demographics
NPI:1174641344
Name:ZIMMERMAN, BRYAN PAUL (IDC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:PAUL
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 EQUINOX LNDG
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-2078
Mailing Address - Country:US
Mailing Address - Phone:401-808-0792
Mailing Address - Fax:757-462-2115
Practice Address - Street 1:2360 AMPHIBIOUS DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8810
Practice Address - Country:US
Practice Address - Phone:757-462-3423
Practice Address - Fax:757-462-2115
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman